Little Leaguer's Shoulder: A Report of 23 Cases
Abstract & Commentary
Synopsis: A more appropriate "guideline for monitoring young pitchers is on the basis of an actual pitch count, recording pitches per inning or per week."
Source: Carson WG Jr and Gasser SI. The Little Leaguer's Shoulder: Report of 23 Cases. Am J Sports Med 1998;26:575-580
From a very large sports medicine clinic, the authors reviewed 23 cases of painful shoulder in adolescents, ranging in age from 11 to 16 years (average, 14 years), who developed pain while playing baseball. Nineteen of the 23 were pitchers, three were third basemen and one was a second baseman. The consistent chief complaint was always pain localized to the upper arm while throwing hard. It occurred in various phases of throwing and was not consistently present in any certain point of the throwing motion. Only one patient had residual, aching pain after throwing was completed. Physical examination consistently revealed tenderness to palpation over the proximal humerus, specifically laterally, in the majority of patients. Only six patients demonstrated any weakness, and swelling was a very uncommon finding. Radiographically the authors identified widening of the proximal humeral epiphyseal plate of the affected humerus when compared to x-rays of the opposite asymptomatic side. Half of the patients also demonstrated some fragmentation, demineralization or sclerosis of the proximal humeral metaphysis.
Treatment consisted of rest from throwing for three months on average. Subsequently 21 of the 23 patients returned to playing baseball and throwing hard without recurrence of any symptoms. The authors did not wait until there was a normal radiographic appearance of the proximal humerus to allow resumption of throwing, if the patient had no symptoms. Only one patient developed premature closure of the physis.
Because of the radiographic findings, the authors likened the injury to an overuse, nondisplaced Salter-Harris I fracture of the proximal humeral physis. Many of the patients in this series, drawn from the greater Tampa area, participate in athletic activities and throwing sports year-round. The authors noted that many of the papers reporting similar cases in the literature were from Texas or California, which also can be considered "year-round sports" states. Young athletes in these areas can practice and throw all year, and even if the number of pitching outings is restricted, overuse may occur from excessive hard throwing. The authors state that a more appropriate "guideline for monitoring young pitchers is on the basis of an actual pitch count, recording pitches per inning or per week."
Comment by James D. Heckman, MD
This is by far and away the largest series of "little leaguer's shoulder" presented in the literature to date. The authors have 23 well documented cases of a painful upper arm caused by throwing hard. The injury seems to occur at those positions on the field where hard throwing is necessary (pitcher, third and second base). The clinical picture is presented very clearly in this article. The radiographic findings are less dramatic. The authors compared external and internal rotation radiographs of the proximal humerus with similar views of the opposite shoulder. In about half of the cases there was very consistent widening of the lateral proximal humeral physis and some fragmentation or sclerosis of the proximal metaphysis. In the other half, however, because of the normally convoluted nature of the proximal humeral physis, the radiographic findings were not that dramatic. Thus, this is primarily a clinical diagnosis which can be treated quite effectively by eliminating throwing for somewhere between 1 and 12 months until the pain with throwing does not recur. If adequate time is given for recovery of the injured tissues, the players have been able to go back to their previous level of competition without a recurrence of the problem.
Prevention of the injury in the first place is a more difficult issue. The condition is not that common and so it is very hard to predict exactly who will develop the syndrome. Since it does appear to be related fairly specifically to hard throwing at specific positions on the field, limitation of the number of hard throws over a given period of time, theoretically, should minimize the problem. Much of the preventive work in this population has been focused on elbow problems, and certainly the same rules should apply and should generally be effective at minimizing the occurrence of physeal injury about the shoulder. Axe et al1 have recommended interval throwing programs for little league baseball players which need to be incorporated into the official rules of youth baseball to minimize the risk of both elbow and shoulder injuries in these young athletes. Physicians treating young athletes should be strong advocates for implementation of these guidelines.
Reference
1. Axe MJ et al. Development of a Distance-Based Interval Throwing Program for Little League Aged Athletes. Am J Sports Med 1996;24:594-602
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content